APH (Antepartum Haemorrhage) and Placenta previa (PP) Diagnosis Symptoms

APH (Antepartum Haemorrhage) and Placenta previa (PP) APH (Antepartum Haemorrhage)

• } It is defined as bleeding from or into the Genital tract.

APH (Antepartum haemorrhage)

Cause of APH

} I. Placenta previa (PP) is defined as the presence of placental tissue over or near the internal cervical os. } PP can be classified into four types based on the location of the placenta relative to the cervical os: to the internal os.

Placenta previa (PP)

• } Type-1/low-lying placenta,
  • ◦ placenta is located near (2 to 3 cm) but not directly adjacent
• } Type-2/marginal previa,
  • ◦ the edge of the placenta lies adjacent to the internal os;
• } Type-3/partial previa,
  • ◦ the margin of the placenta covers part but not all of the internal os;
• } Type-4/complete or total previa,
  • ◦ the placenta covers the entire cervical os;
• } 1. the incidence of PP is 1 in 200 to 1 in 390 pregnancies over 20 weeks’ gestational age).
  • ◦ varies with parity,
  • ◦ For nulliparous, the incidence is 0.2%, in grand multiparous, it may be as high as 5%
• } 2.  The most important risk factor for PP is a previous cesarean section.
  • ◦ PP occurs in 1% of pregnancies after a cesarean section.
  • ◦ The incidence after four or more cs increases to 10%

APH Epidemiology

• ◦ increasing maternal age after age 40),
• ◦ multiple gestation, and previous uterine curettage
• ◦ the placenta covers the cervical os in 5% of pregnancies when examined at midpregnancy.
• ◦ The majority resolve as the uterus grows with gestational age.
• ◦ The upper third of the cervix develops into the lower uterine segment, and the placenta “migrates” away from the internal os.

Other risk factors

• } Unknown —
  • ◦ a.  Endometrial scarring.
  • ◦ b.  A reduction in uteroplacental oxygen promotes need for an increase in the placental surface area that favors previa formation.

APH Etiology

• } Bleeding occur in association with the development of the lower uterine segment in the third trimester.
• } Placental attachment is disrupted because this area gradually thins in preparation for labor.
• } the thinned lower uterine segment is

Cause of bleeding

• } unable to contract adequately to
• } prevent blood flow from the open vessels.shearing action
• } Vaginal examination or intercourse may also cause separation of the placenta from the uterine wall.
• } 80% of affected patients present with painless vaginal bleeding
• } Most commonly, the first episode is around 34 weeks of gestation;
• } one-third of patients develop bleeding before 30 weeks
• } Anaemia

Clinical Manifestations symptoms —

• } Abnormal growth of the placenta into the uterus can result in one of the following 3 complications:
  • } i. Placenta Previa Accreta.
  • } ii. Placenta Previa Increta.
  • } iii. Placenta Previa Percreta.
• } 1.  History.
  • ◦ PP presents with acute onset of painless vaginal bleeding.
  • ◦ A thorough history should be obtained from the patient, including obstetric and surgical history as well as documentation of previous ultrasound examinations.
  • ◦ Other causes of vaginal bleeding must also be ruled out, such as placental abruption.

APH Diagnosis

• } Vaginal sonography –
  • ◦ is the gold standard for diagnosis of previa
  • ◦ Placental tissue has to be overlying or within 2 cm of the internal cervical os to make the diagnosis.
  • ◦ The diagnosis may be missed by transabdominal scan,
  • ◦ if the placenta lies in the posterior portion empty bladder may help in identifying anterior previas, and Trendelenburg positioning may be useful in diagnosing posterior previas.

Complete placenta previa. Sagittal mid-line view of the lower uterus performed tau the placenta (PL) completely covering the cx Marginal/partial placenta previa in 3RD trimester patient with bleeding. Tvu shows inferior edge of posterior pl (P) located at internal CX os

• } If PP is present, digital examination is contraindicated.
  • ◦ a.  A speculum examination can be used to evaluate the presence and quantity of vaginal bleeding, the amount of vaginal bleeding can be assessed without placing a speculum and potentially causing more bleeding.
  • ◦ b.  Maternal vital signs, abdominal exam, uterine tone, and fetal heart rate monitoring should be evaluated.

Examination.

• } 4. . The following laboratory studies should be done for a patient with PP with vaginal bleeding:
  • ◦ a.  Complete blood cell count
  • ◦ b.  Type and cross-match
  • ◦ c.  Prothrombin time and activated thromboplastin time
  • ◦ d.  Kleihauer test to assess for fetomaternal hemorrhage

Laboratory Studies

• } Maternal—
  • ◦ Anaemia with shock or CHF
  • ◦ Malpresentation
  • ◦ Premature labour
  • ◦ Rarly rupture of membrain
  • ◦ Post partum haemorrhage
  • ◦ Sepsis
  • ◦ subinvolution

Complications

• } Foetal complications include
  • ◦ Low birthweight baby
  • ◦ Asphyxia
  • ◦ IUD
  • ◦ Birth injury
  • ◦ Congenital malformation
• } 1. Standard Management
  • ◦ a.  In the third trimester in a patient who is not bleeding, recommendations include
• } ultrasound confirmation
  • ◦ pelvic rest (nothing in the vagina, including intercourse or pelvic exams),
  • ◦ explanation of warning signs and when to seek immediate medical attention,
  • ◦ avoidance of exercise and strenuous activity, and fetal growth ultrasounds every 3 to 4 weeks.
  • ◦ Fetal testing semiweekly